NTSB Cooperative Boating Accident Investigation

Cooperative Boating Accident Investigation
Presented to NASBLA
September 30, 2009, Corpus Christi, Texas
By Rob Henry

Presentation Overview
Brief description of NTSB
NTSB marine accident investigation
NTSB safety recommendations
April 12th Jacksonville, Florida boating accident
Opportunities and challenges

42 Years Ago - 1967-2009
Created in 1967 by the Congress with the authority to investigate aviation, marine, rail, highway, pipeline, and hazmat transportation accidents.
In 1974,Congress made the NTSB completely independent of the DOT.

Mission of the NTSB
The NTSB is charged with
Determining the probable cause(s) of transportation accidents, and
Making recommendations to prevent their recurrence.

The Safety Board Members
The Safety Board consists of five Members, appointed by the President, with the advice and consent of the Senate. Members serve 5-year staggered terms.

Authority to Investigate Marine Accidents
MayInvestigate Any Major Marine Accident Involving a Foreign Vessel Which Occurs in U. S. Waters
May Investigate Any Major Marine Accident Involving a U.S. Ship Anywhere in the World
Shall Investigate Any Collision Between a Public and a Non-Public Vessel
May Investigate Other Marine Accidents of a Recurring Nature

Major Marine Accident Definition
Six or More Lives Lost
Total Loss of a Self-Propelled Vessel of 100 Gross Tons or more
$500,000 or more in Property Damage
Serious Threat to Life, Property, or the Environment From the Release of Hazardous Materials

There Are Many Different Types of Marine Accidents
The Office of Marine Safety Investigates. . .

Collisions

Groundings

Explosions

And Last,

But Not Least . . .

We Also Investigate

Sinkings

There are Many Different Types of Vessels Involved in Marine Accidents, Including . . .

Foreign Passenger Ships

Domestic Passenger Vessels

Commercial Fishing Vessels

Offshore Service Vessels

Offshore Supply

Mobil Offshore Drilling Units

Tankships

Tugboats

Towboats

Barges

Containerships

And Last, But Not Least,

Recreational Boats

Number of Accidents
In An Average Year, About 6000 Commercial Vessel Accidents Reportable To The Coast Guard
About 30-40 Of These Accidents Meet At Least One Criteria For Major Marine Accident
NTSB Investigates Approximately 6-8 Major Marine Accidents Each Year

Independent Investigation Under NTSB Rules
Accident Has Significant Safety Issues
Accident Has High Loss of Life or Major Pollution
Accident Has Wide Public Interest, or
Accident Involves Public Vessel or Major Coast Guard Function

Under NTSB Rules
Launch “GO TEAM”
On 24-Hour Call
365 Days A Year
Enroute In 2 Hours of Notification

Typical Go Team
Investigator-In-Charge
Marine Engineering Group Chairman
Human Performance Group Chairman
Survival Factors Group Chairman
Other Group Chairmen, As Necessary
Fire Science
Metallurgy
Hazardous Materials

Member Launch
Safety Board Member May Launch With Team, Depending Upon Seriousness
Typically will include a public affairs officer and a family assistance specialist.

Investigation to Report
On scene investigation usually takes one to two weeks
Report development will take a year for a complex major marine investigation

Board Meeting
The Board Members conduct a public meeting to discuss and approve a final report on the accident. The final report includes conclusions, a statement of probable cause, and recommendations.

Safety Recommendations
Safety recommendations are the Board’s most important product
They are developed to remedy system, hardware, operational or policy failures identified during investigations

Safety Recommendations
Recommendations are issued to DOT and its modal administrations, DHS (US Coast Guard), manufacturers, transportation operators, trade associations, labor unions and state and local governments

Major Accomplishments
Improved Fire Protection on Cruise Ships
Sprinkler Systems
Smoke Detectors
Improved Lifesaving Equipment on Commercial Fishing Vessels
Life rafts
Survival Suits
EPIRBs
Improved Navigation Safety
Bridge Resource Management Training
Standardization of Integrated Bridge Navigation Systems

“Most Wanted” List
Safety recommendation issuearea selected by the Board for intensive follow-up because it:
Will impact or enhance safety on the national level
Has high public visibility and interest
Can be implemented in a reasonable period of time; and
Is an area that would benefit from this special form of encouragement

NTSB Safety Initiatives
1993 Recreational Boating Safety Study
1998 PWC Safety Study
2006 public forum on life jackets
2006 sole state waters seminar

Prior NTSB Boating Accidents
July 3, 1999, Bayport, MN - Advantage & Bayliner - 5 of 5 fatal
December 29, 1997, Charleston, SC – Morning Dew - 4 of 4 fatal
August 21, 1994, Juneau, AK – Questar - 1of 2 fatal

Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, Florida
April 12, 2009

Arial photos

M/V Little Man II - damage

Crownline 22 damage

Consequences of Accident
14 Passengers – none ejected
5 fatalities
9 seriously injured
3 medevaced to local hospitals
No one walked away from the accident unscathed
Unique opportunity to conduct a Federal-State Cooperative boating accident investigation

Launch
Early decision between NTSB and USCG on Federal primacy
Duty Board Member to launch
Go Team
Notification of launch to Florida FWC
Lead investigator contact
Public affairs contact
Team arrival Jax and press conference

Arrival On Scene
Set Up Command Post
IIC Holds Organizational Meeting
Designates Parties to the Investigation
Explains Ground Rules
Forms Investigative Groups
Groups Disperse to Conduct Investigation
Progress Meetings Every Evening

Party Designation
Organizations are Named as Parties Because they Have Special Knowledge or Resources that the Board Needs to Complete the Investigation.
Party Representatives Can Not Be Lawyers or Insurers & Must Have Technical Qualifications

Parties to investigation
Florida FWC
Region supervisor
5 investigators, 1 PAO
U.S. Coast Guard
Senior investigating officer (LT)
Inspections division chief (LT)

Causal Issues – proximate cause
Human factors
Deceased sitting “operator”
Lacked training and experience, inattention, view obstructions, line of sight, distractions
Surviving standing “operator”
Intoxication, inattention, distractions
Owner of record
Responsibility for oversight of vessel operation, intoxication

NTSB Authority
Issues Subpoenas
Take Testimony Under Oath
May Enter Any Property Where Accident Has Occurred
Copy Pertinent Files and Documents
Order Autopsy of Accident Victims
Test any component of the wreckage

NTSB Resources
Materials laboratory
Transportation disaster assistance/ family assistance
Medical evaluation of autopsies and tox tests. MD on staff
Commercial vessel A/I experience
Weather data retrieval and analysis
Data recorder recovery and analysis
Human factors specialist
Tox laboratory

State Capability and Resources
Accident reconstruction and documentation expertise
Local knowledge
Site security
Logistical support

Challenges to Cooperation
Early communications and coordination
Non-criminal process
Lawyers/due process
Overlapping investigation needs
Interviews
Data and evidence collection
Access to accident site
Limited opportunity to investigate recreational boating accidents

Challenges
Public dissemination of information
Conflicting A/I protocols
Safety vs. law enforcement
Rights of interviewees
Warnings
Immunity
Self-incrimination
Representation
Collection of evidence (rules of, chain of custody)
Transparency of NTSB investigation

Conclusion
Why is mutual cooperation important to each of us?

Judicial Process and NTSB
Board employees may testify once (through deposition or interrogatories) for all civil litigations (49 CFR § 835.5)
NTSB makes available unique factual information not otherwise available
NTSB Board Reports may not be used or admitted into evidence in any action for damages arising from an accident (49 CFR § 835.3)
Interaction with United States Attorneys is rare and limited
General Counsel determines if staff may testify in criminal matter (49 CFR § 835.10)

NTSB and the Coast Guard
Joint Regulations (49 CFR Part 850)
NTSB – USCG Memorandum of Understanding, signed December 19, 2008
Coast Guard a party to NTSB-led investigations
NTSB

NTSB Has Three Options:
Request the Coast Guard to Investigate On Behalf of the Safety Board With No NTSB Participation, or
Conduct a Joint Investigation With the Coast Guard Under Coast Guard Rules, or
Conduct an Independent Investigation Under NTSB Rule.

Investigating Marine Accidents
Entire Marine Investigative Staff Works Out of Washington, D.C. Headquarters
Current Marine Technical Staff - Persons
Master Mariners
Licensed Marine Engineers
Naval Architects
Human Performance
Survival Factors

NTSB Cooperative Boating Accident Investigation

by NASBLA

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